A study of hand hygiene in the postanesthesia care unit--it's about time!

AS a hospital epidemiologist, my inclination when I reviewed the article by Pittet et al. entitled “Hand-cleansing during Postanesthesia Care” was to say, “It’s about time someone addressed this issue in the PACU”! In contrast, readers of the Journal may be asking, “What’s the big deal? These authors haven’t demonstrated that poor compliance with hand-cleansing, or hand hygiene, in the PACU is linked to subsequent nosocomial infections.” If that is how you responded, you are correct when you say the authors did not prove that poor compliance with hand hygiene caused nosocomial infections. In fact, their goal was simply to evaluate compliance with hand hygiene in their PACU. They accomplished this goal and documented that compliance with this basic infection-control measure was as low or lower than that previously reported from intensive care units (ICUs). Before I go further, I want to congratulate the authors for addressing this difficult topic. I also want to congratulate nurses and physicians working in PACUs who take hand hygiene seriously. That said, I’d like to address skeptics in the reading audience. I also would like to address the issue of time—because it is not only about time someone did a study on this topic, but it is also time that makes this a difficult topic to study, and time (or lack thereof) that may prevent some staff from practicing good hand hygiene. Given the brief time that patients are in the PACU, it will be difficult to prove that specific nosocomial infections occurring while the patient is in the surgical ICU or on the surgical ward were caused by the PACU staff’s failure to perform hand hygiene appropriately. However, data from ICUs indicate that patients typically acquire pathogens from the hands of healthcare workers and that hand hygiene decreases the transmission of these organisms and prevents nosocomial infections. I cannot envision a universe in which rules that apply in ICUs do not apply in PACUs. Thus, a Gram-negative organism may be carried on a PACU nurses’ hands from the Foley catheter to the hub of the central venous catheter and from there into the bloodstream of a patient. When signs and symptoms of bloodstream infection are manifest, the patient will be in the surgical ICU. The infection-control program will report the infection to surgical ICU staff, and PACU staff will never receive feedback about that or any other infection. PACU staff members are extremely busy caring for patients who are unstable, in pain, have numerous invasive devices, and require substantial nursing care. Obviously, if the choice is between performing hand hygiene and performing a task that will save the patient’s life, staff members should save the patients’ life. However, this author suspects that staff members infrequently must choose between performing hand hygiene and saving the patient’s life. Instead, I believe that PACU staff and other staff neglect to cleanse their hands because they have not been trained to identify all situations in which hand hygiene should be performed or because the culture in the unit is such that staff members do not put a high priority on this practice. The argument that PACU staff members do not have time for hand hygiene is mitigated in part by the alcoholbased hand-hygiene products available in many hospitals. These products can be placed at the bedside so that staff members do not even need to cross the room to cleanse their hands. Moreover, Voss and Widmer documented that these products reduce by 50–75% the time needed for hand hygiene in an ICU. Two recently published studies are pertinent to the study by Pittet et al. Rogues et al. documented that 33% and 41% of patients carried pathogenic organisms in their nares or on skin adjacent to their surgical sites when they were admitted to the PACU and when they were discharged, respectively. Nineteen percent of staff also carried pathogenic organisms. These investigators concluded that cross-contamination could occur in PACUs and that staff needed education regarding hand hygiene, isolation precautions, and environmental cleaning. Hajjar and Girard conducted surveillance for nosocomial infections related to anesthesia, which they defined as infections occurring within 72 h of a general or regional anesthetic procedure. They identified 25 infections—12 respiratory, 9 vascular catheter–associated, 2 eye, and 2 mouth—for a rate of 3.4 infections/1,000 patients. The infections could have been acquired in the operating room, PACU, or surgical ICU. Although we can’t prove that they originated from errors in the PACU, we also can’t prove that they didn’t. The PACU is usually an open ward without barriers, such as walls, between patients to remind staff members that they need to cleanse their hands when moving from one patient to another. Also, patients usually are not This Editorial View accompanies the following article: Pittet D, Stéphan F, Hugonnet S, Akakpo C, Souweine B, Clergue F: Hand-cleansing during postanesthesia care. ANESTHESIOLOGY 2003; 99:530–5.